Allied Health Professionals with Special Interest. AHPwSI

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Allied Health Professionals with Special
Interest. AHPwSI

• Some experience from Diagnostic Radiography
• Liz Hunt - Radiology Directorate Manager
  Addenbrookes NHS Trust

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Two examples from Diagnostic Radiography

• Direct referral from GPs for barium enemas
  undertaken by Radiographers.
• Waiting list down from 3 months to 2 weeks
• Direct GP referral for women with post menopausal
  bleeding into ultrasound.
• 200-250 outpatient appointments saved per year

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Barium Enema

• Barium is inserted into the bowel via a rectal
  tube
• Air is added to produce double contrast
• The patient is rotated during the test to ensure
  all the bowel is visualised
• Detects cancer, diverticular disease, polyps etc.

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Diagnostic Radiographersperforming Barium Enemas

• The Problem
• Long waiting list for barium enemas
• 2 week wait for cancer referral to diagnosis
• Lists only available when Radiologist available
• SpRs in training must gain competency
• Consultant Radiologists specialising, and
  performing more interventional work

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• The solutions
• Increase the number of sessions
• Vet the request forms more thoroughly
• Decrease the specialist work
• Train interested Radiographers in GI work and
  reward them for their skill

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The method

• Radiographer interested in GI work to undergo
  training
• Leeds theory course
• Practical work supervised by GI Consultant
• 100 barium enemas
• Exam passed and Trust authorizes Radiographer to
  perform the examination
• Reporting done jointly with the Consultant
• ( latest RCOR guidelines advise joint reporting
  by all staff )

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• Radiographer assigned 2 lists per week
• If waiting list rises schedule extra lists
• Second Radiographer undergoes training
• Back up for each other
• No list cancellation
• GP directly refer for barium enemas
• Waiting list gone down from 3 months to 2 weeks
• Quality control assessed by audit

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Results

• High patient satisfaction with excellent patient
  care and reduced waiting list
• High job satisfaction from Radiographer with
  specialist skills
• Recognition as an advanced practitioner in line
  with the 4 tier structure
• High satisfaction with GPs who get fast patient
  diagnosis and can refer on to appropriate
  specialist for treatment as necessary

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Barriers to the process- Before introduction

• This is a teaching hospital we must enable SpRs
  to get enough experience
• How can a non medical member of staff be trained
  sufficiently to understand this
• This is the beginning of the end

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After introduction

• There is a positive impact in SpR training in
  that the Radiographers who have developed great
  expertise can contribute to training
• On audit the diagnostic results for the
  Radiographer are better than those achieved by
  more junior SpRs
• Continual audit provides a standard for the
  service
• Can John cover my list?

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Post menopausal bleeding- Background

• It is a common gynaecological symptom
• Women with PMB should be referred to a cancer
  unit for gynaecological assessment
• Improving outcomes in gynaecological cancers NHS
  Executive 1999
• Traditionally managed by DC and hysteroscopy
• Transvaginal ultrasound can be used as a screen
  for endometrial cancer in symptomatic
  postmenopausal women

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• If the endometrial stripe is uniform and lt5mm in
  thickness likelihood of malignancy is lt1
• This group accounts for 45-50 of referrals
• 50 with ve scans have intra-uterine pathology
  which can be assessed at hysteroscopy
• Direct referral by the GP to ultrasound would
  allow patients with a normal scan to return to
  primary care without the need for a gynae clinic
  appointment

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Diagnostic radiographers trained to perform
ultrasound

• Background in pattern recognition and cross
  sectional anatomy
• 12-18 month training to qualify in ultrasound
  (Post graduate diploma)
• Supervised at every stage
• On qualification can perform ultrasound and give
  a report
• Become an advanced practitioner on proving all
  competencies

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PMB

• Ultrasonographers trained in the use of
  transvaginal scanning scan women with PMB and
  independently report on their diagnosis
• Audit required to try and identify relevant
  patient group and perhaps extend the practice to
  patients with ? Pelvic mass.

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Ultrasound audit

• Data collected for 3 months on all referrals for
  pelvic ultrasound (Nov.2002-Jan 2003)
• Results divided by age into PMB, pelvic mass
  pain, abnormal bleeding and general (330)

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PMB
About 50 PMB occurs between ages of 50-59
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(No Transcript)
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Peak ages for particular gynae problems as
predicted.
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Stakeholder meetings

• GP cancer lead from PCTs
• Gynae Onc Consultant
• Consultant Radiologist
• Ultrasound Radiographer
• Clerical staff from all areas
• Manager from Gynae and Radiology

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Agenda

• To discuss the concept and get agreement
• To discuss the paperwork required
• To identify the patient pathway
• To ensure a fallback for patients who did not
  conform to the pathway
• To clear the hysteroscopy waiting list
• To agree the process
• To keep the referral threshold constant

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Patient Pathway
Examination by GP
Patient referral proforma faxed to gynae onc and
then to us
Patient to GP with PMB
Normal diagnosis . Patient back to GP
Ultrasound within 2 weeks
Patient treated as required
Abnormal diagnosis Patient referred to gynae onc
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Referral Proforma for GP
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Scan Normal
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Scan Abnormal
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Conclusion

• Primary and secondary care working in partnership
  for better patient care
• GP continues to make decisions about referral
  based on their consultation
• Diagnosis and consultation simultaneously saving
  patient journeys to the hospital
• Fast referral for worried women
• Improved use of out patient appointments
• 200-250 appointments saved

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• Radiographers work independently in ultrasound to
  deliver the diagnosis.
• Consultant Radiologist time available for other
  more complex work e.g. neck lump biopsy.
• Next steps
• To audit numbers
• To develop a similar pathway for pelvic masses

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Acknowledgements

• To all my colleagues in Radiology, the gynae
  team, the GPs and our local PCTs
• Thank you for listening